Doctors React to The Pitt S2E13 | Brain Swelling & Severe Asthma

Added: 2026-05-09

[00:00:00]All right, everybody. It's season 2 episode 13 of the pit. Thanks to all of you who've been following along with us.

[00:00:07]Make sure to like and subscribe so we can keep bringing you more content. All right, let's jump in.

[00:00:17]Orlando Diaz, we're treating him for DKA when he left.

[00:00:19]>> How far did he fall? 20 ft or so. Anyone see him pass out?

[00:00:22]>> No, they went looking for him after he didn't answer his radio. On my count, 3 2 1.

[00:00:28]So, this is the guy who had DKA, diabetic ketoacidosis, but left because he was concerned about being able to pay the bill. This is something that we worry about all the time. Patients leave against medical advice, and then we worry about what might happen to them after they leave the emergency department. Like, we actually get really concerned about these folks who have some kind of potentially life-threatening problem and choose to leave the department. So, let's see what happens here. Dr. Ellis on the case.

[00:00:54]Patient, we got this. I'm saying.

[00:00:56]Continuity of care. That was a joke, continuity of care. So, continuity of care is something that we always emphasize in medical care. For example, if you have a primary care doctor that you see over time, that's great continuity of care because the primary care doctor gets to know you. In the emergency department, it's kind of tongue-in-cheek because in theory, we shouldn't be seeing these folks over and over. You come once for an emergency situation, and that's the end of our interaction. So, here he's like making a joke that we commonly make, actually, that like the patient comes back. We're hoping they're not going to come back, but they do, and uh it's continuity of care.

[00:01:31]>> Lungs are up bilaterally. Vitals are stable. Right tip fib hematoma. Deformed right forearm. Dr. Mohan, what do those numbers indicate?

[00:01:38]>> to treat the patient.

[00:01:39]>> reflex.

[00:01:40]>> From increased intracranial pressure.

[00:01:41]Again, trauma. We've been through this so many times. ABCs, airway, breathing, circulation. The patient's intubated in the field. We say that they have uh lungs up bilaterally, so there's no pneumothorax on either side. He's hypertensive, so we're not worried immediately about blood loss. What we are worried about is the high blood pressure and low heart rate. Those potentially together can indicate Cushing's reflex, which is a collection of symptoms and signs that we see when somebody has increased intracranial pressure, high pressure in their cranium, in their brain. In the context of trauma, that usually means blood in the brain. So, we're going to get this patient over to CT scan, take a picture of his head, and see if he in fact has bleeding in his brain from the fall. His sodium looks good.

[00:02:26]>> 24 this morning. He's definitely improving. The DKA is resolving. So, what made him pass out?

[00:02:31]>> It's hot as hell out there. He could have been dehydrated from sweating, or he could have had an NSTEMI, or a posterior CVA. Yeah, so a lot of different possibilities. They're saying that the DKA is improving, so his lab values show an improvement in the diabetic ketoacidosis. But then what made him pass out? It could be an NSTEMI, which is a non-ST elevation MI, a type of heart attack that's not the STEMI type that we talked about earlier that we see on EKG, but the other kind basically that's a non-STEMI, or a posterior CVA, which is a type of stroke. A CVA is a cerebrovascular accident, which is just the technical term for a stroke. And a stroke in the back part of your brain, the posterior part, can lead to a change in balance, which can cause you to fall. So, they're just throwing out all different kinds of possibilities here as far as why he may have passed out. Uh Mr. Haas, pulmonary edema after missed dialysis. I'm Dr. Chen, I'll be back. South 21 next. Dr. Mohan's patient, forearm cellulitis. I can take him. Sold to Dr. Tamarian.

[00:03:27]Moving right along. I'll just point out, so they're doing sign-out here, and sign-out can happen in basically one of two ways. More often, the entire team will go into a back room and discuss each patient one by one, and the oncoming team will assume care of that patient. And it's pretty common for like there's multiple doctors coming in at once, so one of the doctors will raise their hand and say, "I'll take the patient." Or they go round robin, or assign it one way or the other. Here they're doing the same thing, except at the bedside. And that's actually really good practice, because it lets both teams speak to the patient, see the patient in front of them. It reduces the chance of something getting missed.

[00:04:04]Maybe the patient's decompensating out in the department while the team is back in a conference room huddling and going through that list. So, it's actually a great way to do sign-out rounds is just to go bed to bed and actually see and talk to the patient in real time. Barnhill, wheezing and not responding to albuterol. Pulse ox 87, his mother Naomi. Uh mom, history of asthma? Hit whole life. Never dispatched. Barely moving air. Using all his accessory muscles. So, we have an asthmatic uh coming in who's not responding to albuterol. Albuterol is super common. Most of you are probably familiar with that medication from an inhaler. And we give it in a nebulizer as well. EMS will give it on the way.

[00:04:43]We'll also give steroids, we give magnesium. There's a whole uh set of medications that we give for asthmatics.

[00:04:49]Now, of course, there could be something else going on, too. Maybe this isn't asthma, even though the patient has a history of asthma. But typically, like if somebody has a strong history of asthma, if they're wheezing, we really think about asthma first, because with that wheezing, that's such a hallmark of asthma that it it really speaks more toward that disease process than an alternative diagnosis. But of course, we're going to continue to keep our minds open. So, it sounds like this is a pretty sick asthmatic, meaning they're not responding to that first medications that they received in the field. So, let's see what they're going to do from here. Mel, EpiPen? On it. 0.3 milligrams. That may open his lungs for the next few minutes.

[00:05:26]All right, Grady, shot in the thigh.

[00:05:28]So, epinephrine or an EpiPen can be used in asthmatics with a severe asthma exacerbation to help open up the lungs.

[00:05:36]And here they're using an actual EpiPen.

[00:05:38]Sometimes we do use those in a hospital setting, or we'll just draw up epinephrine into a syringe and inject it that way. Just depends on the hospital.

[00:05:46]It's also super common that people run out of their medications or can't access their medications for asthma and it lands them in the emergency department.

[00:05:55]Super, super common preventable issue that unfortunately we see all the time.

[00:06:00]Uh your labs show a lot of inflammation in your liver. Have you noticed a change in your skin coloration?

[00:06:06]I've been using this bronzing cream. Why would my liver be inflamed? Uh there's a lot of possibilities. So, it looks like this patient is jaundiced. She says that she's been using bronzer, so maybe that explains the change in her skin color, but given that her labs are showing signs of, you know, {quote} {unquote} liver inflammation, which I assume is an elevated AST and ALT level. That's what we use to check the liver function along with bilirubin. So, if her bilirubin level is elevated, she's jaundiced. I'd be concerned about some kind of obstructive process in her liver or gallbladder. And the big thing that we don't want to miss is cancer, particularly pancreatic cancer. Painless jaundice is one of the like red flags red flag symptoms of pancreatic cancer.

[00:06:49]So, I hope that's not at all where we're heading with this patient, but something that immediately enters my mind. What's the word? No subdural, no epidural. He's brain swelling with effacement and compression of the ventricles. CT spine, chest, abdomen, pelvis? So, that's unfortunate. They're saying that he has no epidural and no subdural hematoma.

[00:07:09]So, there's no large area of bleeding in the brain. An epidural hematoma is bleeding in the brain outside the dura, the covering of the brain. Subdural is bleeding under the dura and they have two different appearances on CT scan. It sounds like he doesn't have either of those, but he has diffuse swelling of his brain. That in some cases can be even more problematic and indicate a more severe injury. Bleeding we can often do something about. Sometimes neurosurgical intervention can go in and and take out the blood, but when the whole brain is swollen, that can be trickier and in some cases carries a worse prognosis. We got to get this brain swelling down, Samira. How are we going to do that? Samira? What?

[00:07:48]We have to lower the intracranial pressure. Mannitol. Not the best. Can cause diuresis and hypotension.

[00:07:53]>> Hypertonic saline. So, at a high level, to bring down the swelling in the brain, we want to give something through the IV that has the effect of pulling some of that fluid out of the brain. And so, mannitol was a drug that was typically used for this. As they point out here, and again, we're kind of getting into the weeds. There are some disadvantages to using mannitol, and instead they're going to use hypertonic saline, which is like concentrated saline, more concentrated than you would normally get typical like saline in an IV. Like if you go to the hospital, say you're throwing up, and you get a bag of saline hung to rehydrate you, same idea, but it's more concentrated, and by making it more concentrated, it pulls fluid out of the brain. And you know, we see Dr. Mohan here, understandably getting visibly upset. I think that she's taking some of this onto herself, and that she, quote-unquote, let the patient leave.

[00:08:42]Obviously, this patient was going to walk out either way, it seemed, but I think she feels some personal responsibility about that. And yeah, certainly, like again, when patients leave against medical advice, sometimes it can be really distressing to us, because we're charged with the care of the patient, we know what to do for them, and yet we can't like follow through and do it. So, it it can weigh pretty heavily on us providers. Tight as a drum. 5 minutes to see if he can have one more EpiPen. That's a borderline 87.

[00:09:09]How about BiPAP? Turn it up to All right, Brady, shot number two.

[00:09:12]Might as well throw in some magnesium, 50 per kilo. I'm sorry, he's not ventilating. We should be ready to intubate.

[00:09:16]>> Yeah, this is like great bread and butter treatment of a severe asthma exacerbation. They're talking about all these different options. They're giving him more epinephrine. They're going to give him magnesium, which relaxes the smooth muscles of the breathing passages, and helps that open up, so that the patient can breathe more easily. They're going to put him on BiPAP, which is that mask that essentially helps blow air into the lungs, and helps the patient with that ventilation, that movement of air. What they're kind of using the slang for he listens he says, "Oh, he's still tight as a drum." He means he's not moving air. We can we can listen and hear that the patient's not moving air in and out of their lungs, which is basically the problem in asthma that those airways are too constricted to ventilate, to let that air exchange happen. And so, we're talking about the next steps here. He's right that we don't want to put an asthma patient on a ventilator. That can have serious consequences that we try to avoid it if we can. So, here they're going to give him some more time to see if we can avoid that intubation. Saw the scans, this guy needs an EVD.

[00:10:15]External ventricular drain to take down the pressure. Chivardi, feel free to join me. Oh, my my shift was over a while ago. It's kind of an amazing opportunity. So, they are going to put an EVD in, an extraventricular drain to try to relieve that pressure in the skull. So, even though there's no blood to drain, they can still put this EVD in to try to improve the cerebral perfusion pressure as he explains. I also think that as a medical student, you don't always realize that there's an opportunity to see a procedure and you may not get another chance to see it. I think as a student it's like, "Oh, I'm I'm still a student. I'm, you know, I got all these years ahead of training and you know, I'll get to see this again. It's been a long shift and I want to go home." And this is something that like she may never get to see again until she becomes an attending and like maybe not even then. This is not a procedure that's done very often in the ED. So, I think that Dr. Robby gives good advice here. Like, just go see the procedure. It's not something that you're going to necessarily get to see again.

[00:11:09]>> You're going to pass it 5 to 6 cm from the inner table of the skull. Centered, perpendicular, aiming for the medial canthus. All yours. You'll feel a pop when you pass through the ependymal lining. Yeah, so that's super cool and something that is really in the purview of neurosurgery and not emergency medicine. There have been cases in very rural areas where patients have increased intracranial pressure and it's fallen to the emergency department physician to do what's called a burr hole, which is like it's making a hole in the skull to drain some of that pressure to relieve some of that pressure the same as a proper EVD does, but it's something that is only done by emergency medicine like in an absolute last ditch kind of situation. It's really in the purview of neurosurgery.

[00:11:53]No lung sliding on the right.

[00:11:54]Pneumothorax.

[00:11:56]No need to intubate. He has a collapsed lung.

[00:11:59]There was no history of trauma that would have caused a pneumothorax.

[00:12:02]>> What about Dr. King?

[00:12:04]In asthma you can get air trapped. Cool.

[00:12:06]Yeah, great case. So this can happen in asthmatics. The air can build up in the lung. It can't escape because of those constricted airways and it can actually cause a collapsed lung. So here he decompensated. He suddenly got worse and it wasn't because he was just tiring out from his asthma. It was that he actually had a new problem with his lung that can now be fixed. So they're going to decompress the chest. They're going to either put a chest tube in or do just a finger thoracostomy where they just open the chest and relieve that pressure and then put the chest tube in ultimately.

[00:12:37]When the lungs can't fully exhale, eventually they overinflate [music] causing some of the tiny air sacs to burst.

[00:12:45]Like that. They mentioned that there's no history of trauma. Usually when we see a collapsed lung, it's in the setting of trauma, but it can happen in this setting too where the air is kind of stacks and it can't escape from those constricted airways and when that builds up and builds up, it ultimately causes the lung to collapse. His condition will qualify him for Medicare and Medicaid so moving forward, costs should be covered including home health care. Perhaps this isn't the best time.

[00:13:11]>> I just wanted to reassure you about future costs. Is that so messed up? Like we get all this commentary about our screwed up healthcare system. So the asthmatic couldn't refill his medications because of the Medicaid letter being mailed to the wrong place and now we have uh this family member being told that the costs are going to be easier because now her husband's profoundly disabled. Like, I'm just glad that this is being portrayed because it's all totally realistic. Fortunately, like, in the direct immediate care of the patient, for a patient this sick who has this swelling in his brain, we're not usually having this conversation in the emergency department around like long-term costs. But for the asthmatic, it's super realistic because asthmatics come in all the time because they aren't able to access their medications. And this is somebody who almost died because of an administrative, you know, oversight, complication, complexity that just shouldn't happen. So, like, again, kudos to the writers of the Pit for portraying all of this because it is really just a very true and realistic view into what actually goes on in emergency departments around the country. My first day here as a med student, there was a patient I saw a gallstone on the ultrasound, normal EKG, troponin, the pain resolved, and he was in the hall when he had a cardiac arrest.

[00:14:29]>> I think that that's a profound conversation out on the ambulance bay, and I think that it is hard for us to remember every time that we go into work and interact with patients that that patient is having one of the worst days, if not the worst day, of their life. And it's something that we, you know, try to remind ourselves of, but yeah, it's it's uh it's difficult.

[00:14:52]50% one-year mortality. So, he definitely needs surgery. Okay, well, he's a friend, so I will talk to him.

[00:14:57]I'll get him admitted to your service.

[00:14:59]Not today. I think everything gets done over a holiday weekend. He can take it easy at home. He's a ticking time bomb.

[00:15:04]So, he's got an ascending aortic aneurysm, which if it ruptures, would kill him. So, we finally figured out what's going on with Robbie's friend here. It's not super realistic that this patient would just be sent home, even if the cardiothoracic surgeon is not going to do surgery like today on the 4th of July weekend. This patient could still be admitted to the medical service, get these tests done that he's talking about to see cardiology and pulmonology, and then surgery could be done, you know, say in the next couple of days to a week, if this is something that needs to be done urgently. So, it's it's not usually a decision that would get made like on the fly like this. If the emergency doc is worried about an immediately life-threatening problem, typically there is a way to keep the patient in the hospital for further testing and care. So, I think this is dramatized a little bit here. Yeah, a little bit. Boy had a simple buckle fracture, distal radius. He got a Velcro splint.

[00:15:54]And Mrs. Stegman had a small medial meniscus tear. They don't teach us a lot of musculoskeletal ultrasound. I know.

[00:16:00]Uh yeah, super true. Uh we don't learn enough musculoskeletal ultrasound. It's underused and can be used exactly as they're using it here to diagnose musculoskeletal injuries, fractures, sprains, dislocations without x-ray.

[00:16:13]It's not something that we as a specialty get a ton of training on. So, again, the pit writers here pointing out something that we should probably learn more of and use more often. I'm not sure that Al-Shami is fit to run this play. I also don't know if Langdon is going to relapse. I don't know if Whitaker's going to be able to take care of my [ __ ] I'm worried about the people that I care about. We'll all manage until you come back. We always do.

[00:16:34]>> Yeah, what if I don't come back? It's all so sad and high stress and it's just like these uh these practitioners are just pushed to their breaking point. I think fortunately like in most emergency departments, again, it's not as insane as this department is like every minute of every day. But I do think that this speaks to some of the stress that we all carry. You know, I again, I think that like these physicians, these providers are being pushed way past their breaking point, which absolutely happens in departments all over the country. So, I guess the takeaway from this is like we need to not get to this point, right, where where Dr. Robbie is and where some of these other physicians are, and take care of ourselves so that we can take care of patients. I guess that's where I'll leave things for this episode. Uh thanks for watching. Again, season 2 episode 13 of The Pit, and we will see you next time.